History of Spine Surgery in the Ancient and Medieval Worlds

Neurosurg Focus 16 (1):Article 2, 2004, Click here to return to Table of Contents

History of spine surgery in the ancient and medieval worlds

JAMES TAIT GOODRICH, M.D., PH.D. Leo Davidoff Department of Neurological Surgery, Albert Einstein College of Medicine, Children’s Hospital of Montefiore, Bronx, New York

There is a paucity of surviving texts from ancient and medieval times that can shed light on the early development of spine surgery. Nevertheless, the author reviews many of the available books and fragments and discusses early developments in the field of spine surgery from the point of view of physicians’ personalities, general themes, and actual surgical practices. For purposes of an overview and to highlight changing trends in spine surgery, he divides the paper into four eras of medicine: 1) Egyptian and Babylonian; 2) Greek and early Byzantine; 3) Arabic; and 4) medieval.

The early development of surgery of the spine is rather trends in spine surgery over the entire period, I have divid- sparse from the point of view of literature. Very few writ- ed this paper into the following eras: 1) Egyptian and ings from the ancient world have survived. Ancient med- Babylonian medicine, the embryonic period; 2) Greek icine, compared with its modern successor, lacked several and early Byzantine medicine, the historical origins of essentials such as an understanding of anatomy, recogni- spine surgery; 3) Arabic medicine, the prescholastic peri- tion of the concept of disease, and comprehension of the od; and 4) medieval medicine, the period of medical scho- origin of illness in an organic system. The failure to grasp lasticism. these vital principles retarded the practice of medicine and of surgery itself. The practice of neurosurgery and surgery of the spine did not really develop as a discrete EGYPTIAN AND BABYLONIAN MEDICINE: specialty until the 20th century. Despite these limitations I THE EMBRYONIC PERIOD will review some of the existent materials that deal with The Egyptian period encompasses approximately 30 the development of spine surgery in ancient and medieval successive dynasties and holds the claim to have pro- worlds.20 duced the earliest known practicing physician, Imhotep, For the ancient physician, the fear of operating was a who lived in the 14th century BC. For the modern scholar real one, especially when one had to deal with the central interested in studying medical and surgical material from nervous system. Two centuries before the birth of Christ, this epoch, there are only three existing documents that King Hammurabi of Babylon (1955–1912 BC) introduced have any relevance. These are the Ebers, Hearst, and a set of equitable laws that dealt with matters of everyday Edwin Smith papyri, which are discussed later in this life such as marriage, slavery, land purchase, and, of paper.6,9,15,16 course, medicine. The penalties established in this codex We know that anatomical dissection was performed for making surgical errors led surgeons in that period to during this period, but an examination of Egyptian papyri approach patients with some trepidation. In Hammurabi’s also show that the practice of medicine was largely based Code there are nine paragraphs devoted to the physician; on magic and superstition.41 Therapeutic measures de- one in particular deals with the operator who carries a pended on simple principles, most of which allowed na- bronze knife (scalpel) for wound care: ture to provide restoration of health with little interven- If a physician makes a wound and cures a freeman, he shall tion. In cases of injury Egyptian physicians realized that receive ten pieces of silver, but only five if the patient is the immobilization was important and prescribed splints for son of a plebeian or two if he is a slave. However it is decreed that purpose. Their materia medica was impressive, as that if a physician treats a patient “with a metal knife for a shown by their substantial pharmacopeias. severe wound and has caused the man to die—his hands shall Written approximately 500 years after the time of Ham- be cut off” (Code of Hammurabi). murabi, and the oldest medical text believed to exist In this paper I will discuss early developments in the (including ~ 107 pages of hieratic writing), the Ebers pa- field of spine surgery from the point of view of personal- pyrus, is interesting because of its advocacy of surgical ities, themes, and actual surgical practice as revealed in lit- practice. It contains a description, for example, of the re- erature surviving from ancient and medieval worlds. For moval of tumors and recommends surgical drainage of ab- purposes of an overview and to highlight the changing scesses.6

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The Edwin Smith papyrus, written after 1700 BC, dur- tebra of his neck, and he suffers with stiffness in his neck. An ing the time of the New Kingdom, is considered to be the ailment with which I will contend.” oldest book on surgery per se; it comprises a papyrus Treatment: Thou shouldst bind it with fresh meat the first scroll measuring 15 ft in length and 1 ft in width. A total day. Now afterward moor [him] at his mooring stakes until the period of his injury passes by. of 48 cases are discussed in this document, including ones Case Thirty: Sprain in a cervical vertebra. Examination: If in which there were injuries to the spine and cranium. thou examinest a man having a sprain in a vertebra of his neck, Each case includes a diagnosis followed by a formulated thou shouldst say to him: “look at thy two shoulders and thy prognosis. Owing to the scholarly work of James Breas- breast.” When he does so, the seeing possible to him is painful. ted, this papyrus has been translated from the original, Diagnosis: Thou shouldst say concerning him: “One having which is in the possession of the New York Historical a sprain in a vertebra of his neck. An ailment which I will Society, and has been published in a limited edition.9 treat.” Aside from isolated cases found in these remaining pa- Treatment: Thou shouldst bind it with fresh meat the first day. Now afterward thou shouldst treat with honey every day pyri fragments, little can be gleaned from them on the until he recovers. actual practice of surgery and, in particular surgery of the Case Thirty-One: Dislocation of a cervical vertebra. spine. Rather than a direct surgical approach, most authors Examination: If thou examinest a man having a dislocation in a argued for stabilization and allowing nature to run its vertebra of his neck, shouldst thou find him unconscious of his course.15 It is evident from these writings that the Egyptian two arms and his two legs on account of it, while his phallus is physician recognized spine injury to be a most serious erected on account of it, and urine drops from his member problem with an outcome that was almost always fatal. In without his knowing it; his flesh has received wind; his two this section I will review several cases detailed in the Ed- eyes are bloodshot; it is a dislocation of a vertebra of his neck win Smith Papyrus that deal with spine injury. extending to his backbone which causes him to be unconscious of his two arms and his two legs. If, however, the middle verte- Edwin Smith has variously been described as an adven- bra of his neck is dislocated, it is an emissio seminis which turer, money lender, dealer and forgerer of antiquities, pio- befalls his phallus. neer in the study of Egyptian science, and a man of “great Diagnosis: Thou Shouldst say Concerning Him: “One hav- intellectual gifts.”9,15 In 1862 Smith, while in Luxor, ac- ing a dislocation in a vertebra of his neck, while he is uncon- quired the papyrus under controversial circumstances. Al- scious of his two legs and his two arms, and his urine dribbles. though some scholars believe that Smith legitimately pur- An ailment not to be treated.” chased the scroll from an Egyptian businessman named Case Thirty-Three: A crushed vertebra in his neck. Mustafa Agha, others claim that he bought it illegally Examination: If thou examinest a man having a crushed verte- from unscrupulous tomb raiders.9 Regardless of the meth- bra in his neck and thou findest that one vertebra has fallen into the next one, while he is voiceless and cannot speak; his falling ods by which he obtained the manuscript, Smith recog- head downward has caused that one vertebra crush into the next nized its importance and made efforts toward a first trans- one; and shouldst thou find that he is unconscious of his two lation. The papyrus remained in Smith’s possession until arms and his two legs because of it. (Conclusion follows in his death in 1906, after which his daughter donated it to diagnosis). the New York Historical Society. No further inquiry was Diagnosis: Thou Shouldst say Concerning Him: “One hav- made into the secrets of the papyrus until 24 years later ing a crushed vertebra in his neck; he is unconscious of his two when it was “rediscovered” and turned over to James arms (and) his two legs, (and) he is speechless. An ailment not Henry Breasted, an American Egyptologist and archeo- to be treated.” logist. Case 48: A sprain of a spinal vertebra (incomplete). Examination: If thou examinest (a man having) a sprain in a Although the papyrus reveals ancient Egyptian knowl- vertebra of his spinal column, thou shouldst say to him: edge about the heart and its relationship to the pulse, as “Extend now thy two legs (and) contract them both again.” well as functions of the stomach, bowels, and vascular When he extends them both he contracts them both immediate- system, the majority of the cases in the text concern top- ly because of the pain he causes in the vertebra of his spinal ics of neurosurgical interest. It is not surprising, therefore, column in which he suffers. that some of the oldest descriptions of the brain, cerebro- Diagnosis: Thou shouldst say concerning him: “One having spinal fluid, meninges, skull, and cranial sutures can be a sprain in a vertebra of his spinal column. An ailment which I found in the Edwin Smith papyrus. In addition to direct will treat.” observations of trauma and anatomy, Egyptian scholars Treatment: Thou shouldst place him prostrate on his back. appear to have been surprisingly observant, as shown The Edwin Smith papyrus is undoubtedly one of the when they discuss the relationship between injuries of the most significant early medical texts ever discovered. Al- brain and spinal cord and their functional consequences in though valuable to the scientific and nonscientific world, other parts of the body. because of its antiquity and general relevance as the earli- The following cases are reproduced from Breasted’s est medical text, the papyrus is of particular interest and 1930 classic translation.9 value to neurosurgeons because of its specific references to ancient neurosurgical cases. The descriptions of both Case Twenty-Nine: A gaping wound in a cervical vertebra. brain and spinal cord traumas and infections, as well as the If thou examinest a man having a gaping wound in a vertebra of his neck, penetrating to the bone, [and] perforating a vertebra recommended treatments, would assuredly be applicable of his neck; if thou examinest that wound, [and] he shudders to the general population in ancient Egyptian times. The exceedingly, and he is unable to look at his two shoulders and Edwin Smith Papyrus provides modern neurosurgeons his breast [conclusion follows in diagnosis]. . . . with a window in time through which they can wonder at Diagnosis: Thou shouldst say concerning him: “One having the challenges and insights faced by ancient Egyptian a wound in his neck, penetrating to the bone, perforating a ver- healers at the dawn of the medical profession.

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GREEK AND EARLY BYZANTINE PERIOD: The Hippocratic writings contain numerous anatomical THE HISTORICAL ORIGINS OF SPINE descriptions, even though human dissection was not rou- SURGERY tinely practiced. One particular drawback for the contemporary reader of these writings was their lack of graphic Hippocratic School illustration, compelling the reader to visualize and memo- rize his own “picture” of the anatomical description. An- The intellectual evolution of neurological spine surgery other lay in the fact that the Greeks had no anatomical originated in the golden age of Greece with the founding vocabulary at that time; this would not be introduced until of the Alexandrian School in 300 BC (Fig. 1).12 It was then Galen made use of the Latin language. These deficiencies that open dissection was incorporated into formal teach- combined to retard any standardized anatomical proce- ing, providing in a significant step forward. During the dures or the practice of surgery. Despite these drawbacks, Greek period there was not yet any conception of a sur- within the Hippocratic writings, there are a number of geon who, in the strict sense, restricted himself to the interesting histories that do reflect the early practice of practice of “neurosurgery” or to surgery only of the spine. spine injuries.39,40 Spine and head injuries, however, appear to have been A review of Hippocratic texts suggests that actual surg- plentiful, owing to wars and internecine conflicts (as ery on the spine was a great rarity. Stabilization of the graphically recorded by the historians, Herodotus and spine with external splinting was common. Injury to the Thucydides, if not also by Homer). War was then, and still spinal marrow was believed to be quite serious and resul- remains, the primary source of material for the study and tant problems with urinary retention were considered to be treatment of neurosurgical injuries. indicators of the gravity of the injury. Hippocrates wrote In the Iliad Homer describes Achilles’ actions after he about such an injury and laments the presence of charla- had dispensed a fatal blow to his foe: tans who would offer cures that were spurious at best.25,27 Achilles, smiting him with the sword upon his neck, hurled And the spinal marrow would suffer, if from the displace- afar his head and therewithal his helmet; and the marrow spurt- ment of a vertebra if were to be bent even to a small extent; for ed forth from the spine and the corpse lay stretched upon the the displaced vertebra would compress the spinal marrow, if it ground.29 did not break it; and if compressed and strangled, it would Homer continues in a further passage: induce insensibility of many great and important parts, so that the physician need not to give himself any concern about recti- . . . and Hector with his sharp spear struck Eioneus on the fying the displacement of the vertebra, accompanied, as it is, by neck below the well-made helmet of bronze, and loosed his many other ill consequences of a serious nature. It is evident, 28 limbs. then, that such a case could not be reduced either by succession The earliest medical writings from this period are gen- or by any other method, unless one were to cut open the erally thought to be those of Hippocrates (460–370 BC), patient, and then, having introduced the hand into one of the the most celebrated of the Ascelpiadae.25,27 Raised in an great cavities, were to push outward from within, which one Ascepliad family, Hippocrates could trace his ancestry might do on the dead body, but not all on the living. Wherefore, then, do I write all this? Because certain persons through 15 generations directly to Ascelpius. Classical fancy that they have cured patients in whom the vertebra had philologists believe that many of the writings attributed to undergone complete dislocation forward. Some, indeed, sup- Hippocrates, were in reality, composed by members of pose that this is the easiest of all these dislocations to be recov- the Hippocratic School.26,27 The Hippocratic collection ered from, and that such cases do not stand in need of reduc- presents clinical cases based on observation, but only the tion, but get well spontaneously, Many are ignorant, and profit simplest of theories are offered. The concept of a disease by their ignorance, for they obtain credit from those about arising from an organic system was little understood, and them.26 disturbances in “humors” or in certain fluids in the body From this brief clinical note one can see that Hip- were prominent in the elementary Greek view of illness. pocrates and his school clearly did not favor surgical intervention (Fig. 2). External stabilization and immobilization remained the treatment of choice. Besides the expected poor outcomes, there was still the risk of infection, the lack of an antiseptic technique, and minimal anesthesia that kept the Hippocratic school and subsequent generations of surgeons from following any form of aggressive surgical intervention in spine injury.

Herophilus of Chalcedon (ca. 300 BC) From the region of the Bosphorus, among the crowded schools of Alexandria came Herophilus of Chalcedon, a pupil of Praxagoras and Chrisippus and a member of the educated dynasty of the Ptolemies. Unlike his predecessors, Herophilus performed dissection on humans—more than 100, according to his own account—but not on ani- Fig. 1. Photograph showing the Temple of Aescelpius near Per- mals.24,33 He also engaged in the arduous task of devel- gamon, one of the original healing sites in early Greek medicine. oping an anatomical nomenclature and creating a much From the author’s personal collection. needed language for anatomy. In examining the nervous

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work became the first medical manuscript to be printed in 1478.10 Indeed, its publication antedated the printing of works by Hippocrates and Galen. In Book 4, Chapter 10 of De Re Medicina we find his classic description of in- flammation: notae vero inflammationes sunt quattuor, rubor, et tumor, cum calore et dolore. In the field of neurosurgery Celsus made a number of interesting early observations. The one most relevant to this paper was his recognition that a cervical spine fracture could lead to vomiting and difficulty in breathing, and not uncommonly to death. Injury to the lower spine, on the other hand, he demonstrated could cause weakness or paralysis of the leg, as well as urinary retention or incontinence. Again following earlier Hippocratic views, Cel- sus did not recommend surgical intervention but, rather immobilization and stabilization as the key to recovery. Once urinary incontinence or retention occurred he believed that the situation had become quite grave.

Galen of Pergamon (129–200) Galen of Pergamon, whose name is derived from “gale- nos,” which means calm or peaceful, is actually remembered as a contentious and often bitter controversialist. Fig. 2. Illustration showing the Hippocratic treatment of spine Nevertheless, this powerful personality was an original in- injuries—the rack system and the technique of using gravity to straighten the spine. Reprinted from Hippocrates: The Geniune vestigator, compiler, and codifier, as well as a leading pro- Works of Hippocrates (translated by Adams F). London: Sy- ponent of the doctrines of Hippocrates and the Alexan- denham Society, 1844, Vol 2, pp 117–118. drian school. Galen began writing at the age of 13 years and continued to do so until he died at the age of 70 years. His collection of writings overwhelmed the ancient world system, Herophilus traced the anatomical origin of nerves with its size, scope, and influence. Even if we were to to the spinal cord and divided them into motor and sensory eliminate the writings of the Corpus Hippocraticum, Ga- tracts, making an important differentiation between nerves len’s prodigious output would still represent more than and tendons, thus correcting a common earlier error. Hero- 80% of all surviving medical writings of antiquity. The modern edition of his work comprises 22 thick octavo vol- philus was also among the first to describe in detail the 17 ventricles and venous sinuses of the brain, and, in partic- umes. ular, the “confluence of the sinuses,” known also as the Galen had the good fortune to live during the reigns of Torcular Herophili ( = wine press). Having fol- two of the greatest emperors, Antonius Pius (136–161) lowed the writings of the Hippocratic school, Herophilus and Marcus Aurelius (161–180). While he was physician was well aware that injuries of the spinal column and, par- to the gladiators of Pergamon Galen had access to a pleth- ticularly, to those of the spine marrow were invariably ora of human material, particularly patients requiring at- lethal or, at the very least, carried a dismal prognosis. He tention to traumatic injuries. His surgical activities togeth- agreed, therefore, that direct surgical invention on the er with his scientific studies enabled him to make a wide spinal column should to be avoided. range of contributions to neuroanatomy and neurosurgery.8 Among the anatomical experiments he performed Aulus (Aurelius) Cornelius Celsus (25 BC–AD 50) was the transection of the spinal cord, which led him to describe loss of function below the level of the lesion.18,19 Celsus was neither a physician nor a surgeon, but rather In the dog and pig Galen sectioned the recurrent laryngeal an intellectual patrician and a medical encyclopedist. His nerve and recognized that hoarseness was a consequence. writings had an important early influence on surgery and A review of the existent literature shows that he made the he also examined the three contemporary rival medical attempt to identify and number the cranial nerves, of schools: dogmatic, methodic, and empiric. These writings which he demonstrated 11 of the 12; by combining sever- remain a valuable summary of the healing art for this peri- al of these nerves, he arrived at a total of only seven. od. As counselor to the emperors Tiberius and Caligula, Galen discarded Hippocrates’ notion that the brain is only Celsus was held in great esteem. His book, De Re Med- a gland, and attributed to it instead the powers of volun- icina,10,11 was considered one of the most important early tary action and sensation, information that was carried medical documents after the Hippocratic writings. Be- through the spinal cord. This observation was a consider- cause for a time his work was lost, he was one of the few able conceptual advance in medicine.18 major authors not to be transcribed by the Arabists. It was In neurology, too, Galen made a number of critical not until 1443, when an early Celsus manuscript was observations. He recognized that an upper cervical injury uncovered by Thomas Sarazanne (later Pope Nicolas V) can produce a disturbance in arm function. Transecting the that Celsus’ work could be reintroduced to the medical spinal cord at C-2 or higher caused a total loss of sensa- community. With the introduction of moveable type, this tion and motor control from the arms downward.19 Injury

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Unauthenticated | Downloaded 09/27/21 12:25 PM UTC History of spine surgery to the middle or lower cervical spine was demonstrated by a series of cord transections, with results such as paralysis of the chest muscles noted. Galen is remembered for coin- ing the words “kyphosis, lordosis, and scoliosis.” He was among the first physicians to describe Pott disease of the spine and to attribute it to caries in the spine from tuberculosis. He also introduced the “blow bottle” for breathing and lung exercises, and advocated loud singing in an effort to encourage deep breathing and a good pulmonary toilet in the treatment of spine injuries. In a study of spinal cord injury, in particular, he detailed a classic case of what today is known as Brown–Séquard syndrome, that is, a Fig. 3. Text from an early Latin publication in which Paul of hemiplegia with a contralateral sensory loss in a patient in Aegineta describes his treatment of a vertebral injury. Reprinted whom there is hemisection of the cord.19 As a result of his from Paul of Aegineta: Opus de re medica nunc primum inte- vast surgical experience Galen was much more liberal in grum. Cologne: Opera et impensa Joannis Soteris, 1534. advocating surgery than his contemporaries: he offered arguments for elevation of depressed skull fractures, fractures with hematomas, and comminuted fractures, and also recommended the removal of bone fragments, partic- laminar fracture with cord compression, Paul argued that ularly those pressing into the brain and spine. a decompression (that is, a laminectomy) was in the best Historically, the Greek and later Byzantine world ac- interest of the patient. He was the earliest surgeon to do so cepted Galen’s authority without reservation, conferring on a routine basis. In addition to his skills in surgical man- the status of medical dogma to his writings. After Galen’s agement, Paul’s views on wound management were also death there came the demise of any further anatomical quite sophisticated; he made use of wine (which is helpful investigation of the nervous system. Equally unfortunate in antisepsis, although this concept was unknown at the was the lack of any followers or imitators to carry on his time) and he stressed the abstention of compression when work; for all practical purposes ancient science ceased dressings were applied to the brain and spine. altogether after he died. Nonetheless Galen was held in The Greek and early Byzantine periods proved to be an extremely high esteem by later writers and was almost era of scholarship and original investigation, and pro- canonized by Arabic and medieval physicians. Generally duced a group of physicians who were intensely interest- speaking, his anatomical studies were well thought out ed in the better treatment of their patients. As we have and he made a number of new discoveries. As can happen seen, individuals such as Galen of Pergamon, Paul of Ae- in any investigative science, several errors crept into his gineta, Herophilus, and members of the Hippocratic work (for example, rete mirabile), which took time to correct. Approximately 13 centuries elapsed before many of these errors, which had been carefully repeated by subsequent Arabic and medieval physicians and scribes, were finally rectified. The perpetuation of such mistakes had a stultifying effect on new anatomical studies, which were not again seriously undertaken until the Renaissance.

Paul of Aegineta (625–690) Paul of Aegineta, who was trained in the Alexandrian school, was the last of the great Byzantine physicians. He was an influential compiler of works in both the Latin and Greek schools, and his writings continued to be consulted well into the 17th century. His skill as a surgeon, more- over, drew patients from far away. Although Paul venerat- ed the teachings of ancient scholars as tradition required, he also introduced his own methods with good results. His classic work, Seven Books of Paulus of Aegineta,35 contains an excellent section on head and spine injury (Figs. 3 and 4).34 Paul classified skull fractures into several categories: fissure, incision, expression, depression, and arched fractures. Several of Paul’s earlier manuscripts have survived, in which we can find a number of instruments that he designed for neurosurgical procedures: elevators, raspato- ries, and bone biters all originated in this period. Impor- Fig. 4. English translation of Paul of Aegineta’s treatment of a tant to the views presented here was his early endorsement spine column injury with bone fracture. Reprinted from Paul of of spine surgery in cases of spine lamina fractures. In Aegineta: Seven Books of Paulus Aegineta (translated by Adams those cases in which the surgeon thought there might be a F). London: Sydenham Society, 1844–1847.

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Unauthenticated | Downloaded 09/27/21 12:25 PM UTC J. T. Goodrich school all attempted to improve the management of spine injuries and, at the same time, develop a better understanding of spine function. Unfortunately, as we shall observe in the following section, in the prescholastic period of the Arabic and late Byzantine era, neurological investigation and the development of new surgical techniques all but came to a halt. Throughout the medieval period, the treatment of spine injury was considered all but hopeless.

ARABIC MEDICINE, THE PRESCHOLASTIC PERIOD After the great Greek and Roman periods of medicine, the intellectual centers of the discipline shifted to the Ar- abic and Byzantine cultures, whose major influence was paramount from approximately AD 750 until 1200. Eur- ope at this time was to remain intellectually quiescent and unimaginative, now that it was overrun and ruled by “bar- barians” (Huns, Goths, and Norsemen). This was a dormant period in surgery and, in particular, in neuro- and spine surgery. Rather than develop new ideas for medical and surgical treatment, the Arabic schools were satisfied with codifying manuscripts surviving from the Greek and Roman period. Because of the almost incredible zeal of Fig. 6. The anatomy of the skeleton is represented in this early Arabic scholars, the best of Greek medicine was made manuscript leaf from a work attributed to Avicenna. The early available to Arabic readers by the end of the ninth centu- understanding of anatomy was quite primitive among the European and Arabic cutlures. An early Arabic anatomical manuscript from ry. Unfortunately, a rigid scholastic dogmatism became the author’s collection. characteristic of Arabic learning centers, as copyists of the great works of antiquities carried out their translations from Latin, Greek, and Hebrew into Arabic and then systemized the knowledge. Such copyists, too frequently would be uppermost in extremely hot countries, where ca- added their own favorite view of the author and subject, davers putrefy rapidly. Also the Greeks had already ac- sometimes forgetting the correct sense of the original writ- complished most of the anatomical studies of interest and, ing. In fairness, however, the Arabs did preserve the light therefore, the Arabic student of medicine saw no need to of civilization, by maintaining the only camp of learning, duplicate earlier efforts. whereas in Europe at this time the lamp remained unlit The concept of a physician doubling as a surgeon was (Fig. 5). rarely acceptable in the Arabic tradition of medical prac- The religious influence of the Koran has often been tice. Instead, it was expected that the physician would blamed for the absence of originality and progress in Ara- confine himself to writing learnedly, speaking ex cathedra bic medicine; it has been said, for example, that the Ko- and assigning the menial tasks of surgery to an individual ran forbade dissection (Fig. 6). This is only partially cor- of lower class, the surgeon himself. As a result, the ad- rect, however, because practical considerations of climate vances in surgery and anatomy that had been developed by the great Alexandrians, among others, were essential- ly ignored or lost (Fig. 6), whereas the writings of men such as Galen of Pergamon and Paul of Aegineta were merely translated into Arabic and codified. Despite these deficiencies, major Arabic physicians of this period (10th–12th centuries) thrived. Among the most illustrious scholars were Avicenna (980–1037), Rhazes (865–925), Avenzoar (died 1162), Albucasis (1013–1106), and Aver- roes (1126–1198). In the writings of these great physicians one finds an extraordinary effort to canonize the writings of their Greek and Roman predecessors. Thus Arabic scholars and physicians served as academics and guard- ians of what had become hippocratic and galenic dogma. Arabic medicine did introduce a great medical tradition, that of bedside medical care and teaching (Fig. 7). From the point of view of the surgeon, the relative or complete lack of dissection and the practice of surgery (except by Fig. 5. Early anatomical scene from a manuscript based on individuals of inferior status) inevitably reduced any pre- Avicenna, which has been attributed to Serefeddin Sabuncuoglu, occupation with surgical art. The only major contribution ca. early 18th century. From the author’s personal collection. was the reintroduction of the Egyptian method of hot cau-

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advocate surgery for penetrating injuries of the skull, even though patient outcomes were almost always fatal. He introduced the use of animal gut as a material for sutures, and also provided one of the earliest descriptions of spina bifida.

Avicenna (980–1037) An influential physician and philosopher of Baghdad, Avicenna (known as the chief or “second doctor” [the title of “the first doctor” being attributed to Aristotle]) extend- ed the original Greek influence with a force so persuasive and durable it still reaches us today. His works were translated into Latin and became a dominant presence in major European universities well into the 18th century (Fig. 9). His major work Canon medicinae was an encyclopedic effort based on the writings of Galen and Hippocrates, wherein Avicenna’s observations are mostly clinical, bear- ing primarily on materia medica (Fig. 10).7 The Greek word Canon (˘ ´) refers to a straight rod, a carpenter rule, or a standard of measurement. As such, Avicenna’s work became the rule, the codification or benchmark of galenic and Greek medicine. In his Canon medicinae a number of interesting neurological findings can to be Fig. 7. Example of an early Arabic physician using a forceps to found. His greatest contribution must be the detailed remove a foreign body from the forehead. Manuscript attributed to translation of Galen’s collected works, the Opera Omnia. Serefeddin Sabuncuoglu, ca. early 18th century; from the author’s personal collection. Included within this work is one of the earliest and most famous illustrations of a series of spine stabilizations. Within the text are many of discussions of various spine injuries along with the prognoses. In less serious cases the tery to control bleeding, but its use in lieu of the scalpel to use of stabilization and even distraction is advocated to create a surgical incision proved unfortunate (Fig. 8). reduce and align the spine. Despite his advanced thinking, Avicenna was often quite fatalistic in his prognosis of Rhazes (Abu Bakr Muhammad Ibn Zakariya al-Razl these type of injuries. Rarely did he argue for surgical (865–925) interventions because of the often dismal outcomes. The writings of Rhazes demonstrates that he was a scholarly physician, learned in diagnosis, and exclusively Albucasis (Al-Zahrawi 936–1013) loyal to the Hippocratic teachings.36 Although primarily a In the Arabic tradition Albucasis was a great compiler court physician and not a surgeon, he nevertheless left as well as a serious scholar, whose writings (~ 30 vol- writings on surgical topics that continued to be influential umes) mainly focused on surgery, dietetics, and materia through the 18th century. Rhazes was one of the first phy- medica. In his introduction to the Compendium, there is an sicians to introduce the concept of “concussion” and to interesting discussion of why Arabic scholars made so lit-

Fig. 8. Example of the application of the cautery for the treat- Fig. 9. Illustration showing the use of a rack to straighten the ment of wounds and bleeding. Manuscript attributed to Serefeddin spine. From an early manuscript (attributed to Serefeddin Sab- Sabuncuoglu, ca. early 18th century; from the author’s personal uncuoglu, ca. early 18th century) on the subject of Avicenna and collection. the treatment of spine injuries. In the author’s personal collection.

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lesser spinal injuries, some methods advocated by Albu- casis for injury reduction were rather dangerous in design, depending on a combination of spars and winches. He held that bone fragments in the spinal canal should be re- moved.1–4 Chapter nine: On setting the vertebrae of the back and neck When a fracture occurs in the bones of the neck, which is rare, as mostly they suffer contusion, as do the spinal vertebrae—when it happens to anyone and you want to know where it will heal or not, then look and if you see both his hands relaxed and numb and dead and he has no power to move or stretch or close them, and when you pinch them or prick them with a needle he does not notice it or feel any pain in them, you may know, as a general rule, that it will not mend, for he is doomed. But if he moves them both and feels in them the pinching and pricking, you may know that the spinal medulla is still intact and that under treatment the patient will recover. If anything of this nature happens to the vertebrae of the back and you wish to know if he will recover or not, then pay attention to his feet. If you see them relaxed and in the situation we described in the case of the hands, and when he lies on this back he passes flatus and faeces involuntarily, and lying prone he passes water involuntarily and lying on his back he cannot pass water if he wishes, then you may know this case is hopeless, so do not concern yourself with his treatment. But if noth- Fig. 10. An early printed example of the treatment of spine ing of this kind occur then the case is easier. injuries in a work by Avicenna. Illustrated here are some of the The way to treat this latter kind of case is to try to reduce examples of spine stablization. From Avicenna: Liber Canonis, the swelling by applying over the injured vertebra oil of roses. . De Medicinis Cordialibus, et Cantica. Basel: Per Joannes Heru- . . If the injury is accompanied by fragmentation or a separation agios, 1556. of part of the bone, you must cut down on it and remove the bone; then bring together the edges of the opening, by suture if it be wide; then treat with granulating ointments until it heals. tle progress in surgery; he attributed this to a lack of ana- If the last bone of the coccyx, which is the sacrum of the tomical study and an inadequate knowledge of the clas- tail, breaks, introduce the thumb of your left hand into his anus sics. His popularization of the frequent use of emetics as and reset the bone with other hand in whatever way is possible and affords the best setting . . . if you perceive a fragment in prophylaxis against disease has survived in the prescrip- the fracture, cut down upon it, remove it, and dress the wound tion of “purging,” a therapy that was continued into the as before said, until it heals.3 19th century. The final section of the Compendium consists of a lengthy summary of the surgical techniques practiced at MEDIEVAL MEDICINE, THE PERIOD OF 1–4 that time. Albucasis’ work, which featured unique illus- MEDICAL SCHOLASTICISM trations of surgical instruments, was used extensively in the schools of Salerno and Montpellier and, hence, be- With the demise of the Arabic schools and the transition came an important influence during the medieval period. to medieval scholasticism, a new concept developed in Many of the instruments featured were designed by Albu- which philosophical and metaphysical explanations and casis himself and in the Compendium he describes them dialectical interpretations became prominent in the med- together with the technical aspects of their use. His design ical schools. A leading school at this time was that of Sal- of a “nonsinking” trephine is classic and provided the ba- erno, where despite the barbarian invasions, physicians sis for the patterns of many later instruments: it involved were trained, libraries maintained, and a medical school the addition of a collar surrounding the trephine in a cir- was permitted to flourish (Fig 11).5 cular fashion to prevent plunging. Some of the instruments Albucasis described were modeled on those de- Constantinus of Africa (1020–1087) scribed by Paul of Aegineta; the practical reputations of these tools were evidently enhanced by their inclusion in An important leader and educator in this institution, and the Compendium. a product of medical scholasticism, was Constantinus Albucasis’ treatise on surgery is an extraordinary work. Africanus—magister orientis et occidentis—an important figure in the school of Salerno (Magistri Salernitani), who It is a rational, comprehensive, and well-illustrated text introduced Arabic medicine to that region and hence to designed to teach the surgeon the details of each treat- all Europe.13 Constantinus studied at Baghdad, where he ment, including the types of wound dressings to be used. came under the influence of the Arabists, and later retired Albucasis recognized the diagnosis of spinal injury, par- to a monastery at Monte Cassino where he translated ticularly dislocation of the vertebrae, and in cases of total Arabic manuscripts into Latin, albeit rather inaccurately. subluxation he appreciated that the prognosis was essen- Some historians considered him no more than an unscru- tially terminal, with the patient showing involuntary activ- pulous plagiarist and unreliable translator, but he did ity (passing urine and stool) and flaccid limbs. Regarding translate texts from Arabic to Latin (his writings mark the

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tradition, the first writer on surgery in Italy. His work, Practica chirurgiae,38 had a tremendous influence on the medieval period, offering several interesting surgical techniques (Figs. 12–14). Roger introduced an unusual technique of checking for a tear in the dura mater or a leakage of cerebrospinal fluid in a patient with a skull fracture: while the patient held his breath (Valsalva maneuver), the surgeon watched for a cerebrospinal fluid leak or air bub- bles. A pioneer in the techniques of managing nerve injury, Roger argued for the reanastomosis of severed nerves and paid particular attention to the nerves’ alignment. In a 12th century manuscript attributed to Roger of Salerno (only recently translated from the original and formerly owned by Harvey Cushing), there is an interesting review of Salernitan surgery, the so-called “Bamberg surgery.” There is an early description of the use of a soporific mixture used to induce relief of pain in a patient about to undergo surgery. This medication was composed of the bark of a mandragora, hyoscyamus, and levisticum seed, which were mixed together, ground, and then applied wet to the forehead of the patient.14 In the field of anatomy Roger offered little new, contenting himself with recapitulating earlier anatomical treatises, in particu- Fig. 11. An early illustrated work dealing with the school of lar, those of Albucasis and Paul of Aegineta. In the surgi- Salerno. The cover shows Constantine the African lecturing to the cal treatment of spinal disorders and fractures, this author school. From Anastasius, Arnaldus, Camerarius J, et al: Regimen followed the guidelines of the early classicists by favoring sanitatis Salernitanum. Conservandae bonae valetudinis prae- stabilization in cases of spinal subluxation. An important cepta longe saluberrima, regi Angliae quondam a doctoribus early manuscript kept in the British Library (Sloane Man- scholae Salernitantae versibus . . . . per Joannem Curionem . . uscript No. 1977) contains illustrated examples of patients . . Franc: Apud haeredes Christiani Egenolphi, 1573. with spinal injuries. In summary this was a period in European history char- acterized by the devastation of war, famine, pestilence, earliest transfer of Arabic medical literature to the West). Thus began a new translation of medical texts back again into Latin (continuing the legacy of Galen), with the Hip- pocratic writings remaining the inexhaustible source of medical and surgical information.13 Constantinus’ example allows one to gauge how much medical and surgical knowledge was lost or distorted by inaccuracies in the course of successive translations, particularly those of anatomical works. It is notable that Constantinus reintroduced anatomical dissection by performing an annual dissection of a pig, but, unfortunately, the anatomical observations that were made as the dissection progressed were compared with those recorded in classical Greek works, and any contemporary finding that did not match that of the ancient texts was simply ignored. Constantinus is representative of a period of extensive compilation in which an original thought or advance in knowledge was notable chiefly by its absence. From this period, however, came the Regimen Sanitatis Salernitum, the Salernitan directions for health, a work that first appeared in the 12th century and later was reproduced in approximately 140 different editions. Despite a strong educational system and a devotion to health care, this remained a period in which surgical education and practice continued to slumber. A review of the surgical texts produced at this time basically show only a reiteration of the writings of Hippocrates, Galen, Paul of Aeginea, and the other classical figures. Fig. 12. An illustrated leaf from an important early manuscript Roger of Salerno (ca. 1170) on the works of Roger of Salerno. The concepts of “professor” and teaching within the Church guidelines are clearly evident here. Roger of Salerno was a surgical leader in the Salerno Courtesy of the British Museum, Sloane Manuscript Collection. Manuscript No. 1977.

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Fig. 13. An illustrated leaf from an important early manuscript Fig. 14. An enlargement of one of the panels shown in Fig. 13 on the works of Roger of Salerno. Illustrated here are some early demonstrating treatment of a spine injury. The typical treatment surgical treatments, including some neurosurgical and spine treat- consisted of using gravity and extension of the spine to treat a cur- ments. Courtesy of the British Museum, Sloane Manuscript Col- vature. Courtesy of the British Museum, Sloane Manuscript Col- lection. Manuscript No. 1977. lection. Manuscript No. 1977. and general malaise. Medical knowledge was carefully nons were being manufactured in Ghent. Handguns first guarded by monastic recluses in inaccessible mountain re- appeared in the middle of the 15th century, although they treats. Despite this state of affairs some surgeons evident- were quite massive and clumsy to use. (Many examples ly succeeded in mastering their art in the midst of intel- can still be seen in European museums.) In 1515 a Nurem- lectual darkness. berg inventor created a wheellock mechanism, which led to the development of the musket, a weapon that proved to Theodoric of Cervia (Borgognoni) (1205–1298) be devastating in battle, thus producing of much material for the surgeon. An unusually inventive medieval surgeon, Theodoric of Cervia (also known as Theodoric Borgognoni of Lucca) is William of Saliceto (1210–1277) remembered as a pioneer in the use of aseptic technique— not the “clean” aseptic method used today, but rather one The ablest Italian surgeon of the 13th century and a based on the avoidance of “laudable pus.” Theodoric at- professor at the University of Bologna, William of Sali- tempted to discover the ideal conditions for good wound ceto wrote Chirurgia,43 which was highly original and not healing and concluded that they consisted of control of based on previous writings. Although William rarely bleeding, removal of contaminated or necrotic material, quoted his sources, the work shows the influence of Galen avoidance of dead space, and careful application of a and Avicenna. Book IV of Chirurgia is particularly impor- wound dressing that had been bathed in wine. tant because it contains the first section dealing with re- Theodoric’s surgical work, written in 1267, provides gional or surgical anatomy. A major advance promoted at one of the best views of contemporary medieval surgery.42 the time by William was replacing the Arabic method of He argued for meticulous (almost halstedian) surgical burning with cautery with the use of the surgical knife. techniques. The aspiring surgeon trained under competent William’s other great contribution was devising a series of masters and seems to have been well read in the field of techniques for nerve suture anastomosis. Unfortunately, surgery. To assist the patient in tolerating surgery, he de- his works on fractures and disorders of the spine basically veloped his own “soporific sponge,” containing opium, reiterate earlier views that these lesions are rarely treatable mandragora, hemlock, and other less important ingredi- and they reflect a very conservative attitude toward sur- ents, which was applied to the patient’s nostrils until the gery of the spine. individual fell asleep. An important change in the type of wounds managed by Leonard of Bertapalia (1380?–1460) surgeons occurred midway through the 13th century with Leonard of Bertapalia was a prominent figure in 15th the introduction of gunpowder into Europe by the Fran- century surgery. Originating from a small town near Pa- ciscan Friar Roger Bacon, and its prompt use in military dua, he established an extensive and lucrative practice in endeavors. By the second half of the 14th century, can- that area and in neighboring Venice. Among the earliest

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Unauthenticated | Downloaded 09/27/21 12:25 PM UTC History of spine surgery proponents of the study of anatomy, Leonard offered a surgery. He offered some new wound treatments (opting course of surgery in 1429 that included the dissection of for cleanliness and avoiding “laudable pus”) and argued an executed criminal. Leonard appears to have had a for healing by primary intention—an original concept for strong interest in injuries of the head, because he devoted this period (“modus novus noster”23). In the surgical treat- one third of his book to surgery of the nervous system.31,32 ment of wounds he argued for removal of foreign bodies He considered the brain and spine to be the most precious and the use of wine dressings in wound care—the wine of organs, regarding them as the source of voluntary and acting as an antiseptic and providing better healing. Henri involuntary functions. His insights into fractures were re- began writing his treatise on surgery in 1306, but was markable. He proposed that the physician always avoid unable to finish it because of poor health (tuberculosis). materials that might cause pus; never use a compressive He was also a designer of surgical instruments and, in par- dressing that might drive bone into the brain or spine; and ticular, is remembered for the creation of a special needle if a piece of bone is piercing, remove it. His philosophy holder and also an instrument for extraction of arrow- closely resembles that of a much earlier surgeon, Paul of heads. The inclusion of illustrations in his Chirurgie, es- Aegineta. pecially anatomical depictions, was of great importance Leonard assembled a set of rules to guide the practice to Henri. His work is considered the first to actually make of a 15th century surgeon that still remain applicable five use of illustrations for teaching purposes, a concept un- centuries later. heard of in the 14th century, but widely accepted since the To . . . be the perfect surgeon, you must always bear in Renaissance. mind these eight notations, and remembering them you will be preferred to others. The first task . . . to become a good surgeon Guy de Chauliac (1300–1368) should be to use his eyes. . . . Second, you must accompany and observe the qualified physician, seeing him work before The most influential surgeon of the 14th and 15th cen- you yourself practice. . . . Third, you must command the most turies and a writer who demonstrated rare learning and a gentle touch in operating and treating lest you cause pain to the fine historical sense, Guy de Chauliac exerted an influ- patient. . . . Fourth, you must insure that your instruments be sharp and unrusted whenever you cut anywhere. . . . Fifth, you ence so great that he became physician to three popes at must be courageous in operating and cutting but timid to cut in Avignon (Clement VI, Innocent VI, and Urban V) and a the vicinity of nerves, sinews and arteries, and, so as not to leading surgeon at the school of Montpellier. His work commit error, you should study anatomy, which is the mother was copied and translated well into the 17th century and of this art . . . perform your surgery cleverly and never operate was considered to be the principal didactic surgical text on human flesh as if you were working on wood or leather. . . . (Collectorium cyrurgie, AD 1363) of this period (Fig. Sixth, you must be kind and sympathetic to the poor, for piety 15).21,22 Guy posited four conditions that must be satisfied and humility greatly augment your reputation and the sick will more freely commit themselves to your care. Seventh, you must for a practitioner to be a good surgeon: 1) the surgeon never refuse anything brought you as a fee, for the sick will should be learned; 2) he should be expert; 3) he must be respect you more. Eighth, you must never argue about fees with ingenious; and 4) he should be able to adapt himself (from the sick, or indeed demand anything unless it be previously the introduction of Ars Chirurgica). Guy advocated repair agreed upon, for avarice is the most ignoble of vices and should by primary suture and claimed good results. He used egg you be so inflicted, you will never achieve the reputation of a albumin to stop bleeding and provide adequate hemosta- good doctor.32 sis, which always posed a difficult problem for surgeons. Lanfranchi of Milan (died 1306) A major error on his part was to reintroduce the concept of laudable pus to the healing of wounds, which set back Lanfranchi of Milan, a pupil of William of Saliceto and surgery approximately 600 years, until the time of Lord often called the father of French surgery, carried forward his teacher’s use of the knife in place of the cautery. Al- Lister in the latter half of the 19th century. Guy’s chief though Italian by birth, Lanfranchi was driven from Italy work on surgery was divided into three parts, the second to France early in his career because of political strife. Af- of which deals with a number of subjects, most particular- ter seeking refuge in France, he produced his Cyrugia ly with wounds, fractures, and dislocations. A combina- parva, a work in which he perfected the use of the suture tion of accurate anatomical explanations, careful surgical for repairs.30 An innovative surgeon, Lanfranchi devel- diagnoses, and superb medical ethics pushed this surgeon oped a method of esophageal intubation for surgery, a to the forefront. In addition to his surgical skills Guy ad- technique not commonly practiced until the 20th century. vocated patient comfort and for this he used a narcotic As an educated surgeon he attempted to elevate the art and sponge for anesthesia. He was not fearful about cutting science of surgery above the mediocre level of the bar- out superficial tumors, yet was cautious in cutting for the ber–surgeon. In a traditional medieval fashion his treat- stone. He treated fractures and dislocations with splinting ment of spine lesions and trauma mirrored earlier views of and suspension, often using a weight-and-pulley system stabilization. A bad prognosis was clearly evident in a pa- similar to that advocated by Avicenna. The writings of tient who was unable to move his legs, one who was in- Guy de Chauliac remained influential in Europe until the continent, or one who could not control his bowels. There publications of Ambrose Pare in the 16th century. The is no discussion of actual surgery on the spine and thus it first printed edition of Guy’s work appeared in 1478; it is unclear whether he would have advocated this form of was followed by approximately 70 editions over the next treatment. several centuries, proving to be a most influential work. Henri de Mondeville (died 1317) Guy de Chauliac had this to say about the treatment of wounds: Henri de Mondeville, who taught at Montpellier, was an (1) To remove foreign bodies, if there be any between the important figure in the history of French medicine and divided parts.

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necnon practicae Alsaharavii. Augsburg: Impensis Sigismun- di Grimm & Marci Vuirsung, 1519 2. Abu al-Qasim Khalaf ibn Abbas al-Zahrawi: On Surgery and Instruments (translated by Spink MS, Lewis GL). Berkeley, CA: University of California Press, 1973 pp 170–172 3. Abu al-Qasim Khalaf ibn Abbas al-Zahrawi: On Surgery and Instruments (translated by Spink MS, Lewis GL). Berkeley, CA: University of California Press, 1973 pp 735–777 4. Abu al-Qasim Khalaf ibn Abbas al-Zahrawi: On Surgery and Instruments (translated by Spink MS, Lewis GL). Berkeley, CA: University of California Press, 1973 pp 812–819 5. Anastasius, Arnaldus, Camerarius J, et al: Regimen sanitatis Salernitanum. Conservandae bonae valetudinis praecepta longe saluberrima, regi Angliae quondam a doctoribus scholae Salernitantae versibus . . . . per Joannem Curionem . . . . Franc: Apud haeredes Christiani Egenolphi, 1573 6. Anonymous: The Papyrus Ebers. The Greatest Egyptian Medical Document (translated by Ebbell B). Copenhagen: Le- vin & Munksgaard, 1937 7. Avicenna: Liber Canonis, De Medicinis Cordialibus, et Can- tica. Basel: Per Joannes Heruagios, 1556 8. Awad IA: Galen’s anecodote of the fallen sophist: on the cer- tainity of science through anatomy. J Neurosurg 83:929–932, 1995 9. Breasted JH: The Edwin Smith Surgical Papyrus. Chicago: University of Chicago Press, 1930 Fig. 15. Title page from a printed work on several early and 10. Celsus AC: De Medicina. Florence: Nicolaus Laurentii, 1478 prominent medieval physicians and surgeons, including the works 11. Celsus AC: Medicinae Libri VIII. Venice: In aedibus Aldi, et of the great French surgeon Guy de Chauliac. From Guy de Andreae Asulani soceri, 1528 Chauliac: Cyrurgia . . . Et Cyrurgia Bruni. Teodorici. Rolandi. 12. Chapman PH: The Alexandrian Library: crucible of a renais- Lanfranci. Rogerii. Bertapalie. Noviter impressus. Venetiis: Per sance. Neurosurgery 49:1–14, 2001 Bernardinum Venetum de Vitalibus, 1519. 13. Constantinus Africanus: Constantini Africani Post Hippocra- tem et Galenvm, qvorum, Graece linguae doctus, sedulus . . . . Basileae: Apvd Henricvm Petrvm, 1536 (2) To bring together the divided parts. 14. Corner GW: On early Salernitan surgery and especially the (3) To unite the parts drawn together. “Bamberg Surgery” with an account of a previously unde- (4) To conserve and preserve the tissues. scribed manuscript of the Bamberg surgery in the possession of (5) To correct accidents.37 Dr. Harvey Cushing. Bull Inst Hist Med 5:1–32, 1937 15. Elsberg CA: Edwin Smith Papyrus and diagnosis and treatment of injuries to skull and spine. Ann Med Hist 3:271–279, 1931 CONCLUSIONS 16. Feldman RP, Goodrich JT: The Edwin Smith surgical papyrus. Childs Nerv Syst 15:281–284, 1999 The Arabic and medieval era were periods of great in- 17. Galen: Opera Omnia (editionen curavit Kühn CG). Lipsiae: C tellectual activity, but also of somnolence as far as origi- Cnoblock, 1821–1833 nality of thought is concerned. Faith in the teachings 18. Galen: Omnia quae extant in Latinum sermonem conversa. of antiquity was excessive. From the fall of the Roman Venetiis: Apud haeredes Lucaeantonii Juntae, 1576 Empire until the beginning of the 16th century, anatomy 19. Galen C: Experimental section and hemisection of the spinal and the practice of surgery, with only rare exceptions, lay cord (taken from De Locis affectibus). Ann Med Hist 1: dormant, chained to a staunch galenic orthodoxy. The 367–371, 1917 translation of writings from Latin, Greek, and Hebrew in- 20. Goodrich JT: Neurosurgery in the ancient and medieval worlds, in Greenblatt SH, Dagi TF, Epstein MH (eds): A History of to Arabic and back into Latin resulted in many errors of Neurosurgery: In Its Scientific and Cultural Contexts. Chi- interpretation. Lack of true anatomical knowledge and cago: AANS, 1997, pp 37–64 poor surgical outcomes naturally led physicians to recom- 21. Guy de Chauliac: Cyrurgia . . . Et Cyrurgia Bruni. Teodorici. mend against operating on spine and the spinal cord. A Rolandi. Lanfranci. Rogerii. Bertapalie. Noviter impressus. review of early treatises shows that, despite intellectual Venetiis: Per Bernardinum Venetum de Vitalibus, 1519 paralysis, there still existed a number of prominent per- 22. Guy de Chauliac: Guy de Chauliac (A.D. 1363) On Wounds sonalities who did make some advances. It was not until and Fractures (translated by Brennan WA). Chicago: WA the 19th century, however, with the introduction of cere- Brennan, 1923, p 81 bral localization, antisepsis, and anesthesia, that the “mod- 23. Henri de Mondeville: Chirurgie . . . Composée de la 1306 à ern” development of neurosurgery flourished. 1320. Paris: Félix Alcan, 1893 The history of medicine consists of a successive series of 24. Herophilus: The Art of Medicine in Early Alexandria (trans- intellectual movements proceeding from different centers and lated by von Staden H). Cambridge, UK: Cambridge University each engulfing its predecessor.41 Press, 1989 25. Hippocrates: Aphorismi, cum Galeni commentariis, Nicolao Leoniceno interprete, Praedictiones, cum Galeni commen- References tariis, Laurentio Laurentiano interprete. Paris: Simonem Colinaeum, 1527 1. Abu al-Qasim Khalaf ibn Abbas al-Zahrawi: Liber theoricae 26. Hippocrates: The Geniune Works of Hippocrates (translated

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by Adams F). London: Sydenham Society, 1849, Vol 2, pp 36. Rhazes ABM: Opera parva. Lyon: Impressa per Gilbertum de 117–118 Villiers, impensis Johannis de Ferris, 1511 27. Hippocrates: - 37. Riesman D: The Story of Medicine in the Middle Ages. New Magni Hippocratis Medicorvm Om- York: PB Hoeber, 1936, p 211 nivm Facile Principis, Opera Omnia quae extant . . . nunc denuo 38. Roger of Solerno: In Guy De Chauliac: Cyrurgia . . . Et Latina Interpretations & Annotationbus illustrata Anutio Foesio Cyrurgia Bruni. Teodorici. Rolandi. Lanfranci. Rogerii. . . . . Genevae: S Chouet, 1657–1662 Bertapalie. Noviter impressus. Venetiis: Per Bernardinum 28. Homer: Iliad (translated by Murray AT). Cambridge, MA: Venetum de Vitalibus, 1519 Harvard University Press, 1999, Vol 2, Ed 2, Book VII, Lines 39. Sahlas DJ: Functional neuroanatomy in the pre-Hippocratic 11–12 era: observations from the Iliad of Homer. Neurosurgery 48: 29. Homer: Iliad (translated by Murray AT). Cambridge, MA: 1352–1357, 2001 Harvard University Press, 1999, Vol 2, Ed 2, Book XX, Lines 40. Sanan A, Rengachary SS: The history of spinal biomechanics. 481–483 Neurosurgery 39:657–669, 1996 30. Lanfranchi of Milan: In Guy De Chauliac: Cyrurgia . . . Et 41. Singer CS: A medical compendium of the first half of the Cyrurgia Bruni. Teodorici. Rolandi. Lanfranci. Rogerii. twelfth century. Manuscript 17, St. Johns College, Oxford Bertapalie. Noviter impressus. Venetiis: Per Bernardinum about A.D. 1110. Bull Soc Med Hist 11:53–96, 1917–1922 Venetum de Vitalibus, 1519 42. Teodorico de Borgognoni: The Surgery of Theodoric ca. A.D. 31. Leonard of Bertapalia: In Guy De Chauliac: Cyrurgia . . . Et 1267 (translated by Campbell E, Colton J). New York: Apple- Cyrurgia Bruni. Teodorici. Rolandi. Lanfranci. Rogerii. ton-Century-Crofts, 1955–1966 Bertapalie. Noviter impressus. Venetiis: Per Bernardinum Venetum de Vitalibus,1519 43. William of Saliceto: Chirurgia. Venice: F di Pietro, 1474 32. Leonard of Bertapalia: On Nerve Injuries and Skull Frac- tures (translated by Ladenheim JC). Mount Kisco, NY: Futura Publishing, 1989, pp 53–55 Manuscript received November 3, 2003. 33. Marx KFH: Herophilus: ein Beitrag sur Geschichte der Accepted in final form December 11, 2003. Medicin. Carlsruhe: Marr, 1838 Address reprint requests to: James Tait Goodrich, M.D., Ph.D., 34. Paulus of Aegineta: Opus de re medica nunc primum inte- Leo Davidoff Department of Neurological Surgery, Albert Einstein grum. Coloniae: Opera et impensa Joannis Soteris, 1534 College of Medicine, Children’s Hospital of Montefiore, 111 East 35. Paulus of Aegineta: Seven Books of Paulus Aegineta (trans- 210th Street, Bronx, New York 10467. email: goodrich@ lated by Adams F). London: Sydenham Society, 1844–1847 aecom.yu.edu.

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